Abstract

Background and objective Cardiff and Vale out-of-hours
service (Wales, UK) adopted the ‘expert triage’ service model in
April 2013. The purpose of the model was to train and support
General Practitioners (GPs) to provide high quality triage in
terms of process and outcomes. The aim of this study was to
analyse effects on triage outcomes and to examine patient and
GP experiences of the ‘expert triage’ service model.
Method Triage outcomes of telephone advice, primary care
centre appointments, home visits, and Accident & Emergency
referrals were analysed as a ‘run chart’; a graph used to depict
changes across time. Telephone interviews were conducted with
samples of participating GPs and patients, which considered
patient understanding and use of triage information and GP
perception of the changes adopted by the new model. Interview
responses were coded and analysed thematically as themes and
subthemes.
Results Primary Care Centre appointments and referrals
to A&E departments declined after introduction of the
expert triage model. Patient understanding and use of triage
information was similar for previous model and expert triage
patients. There appeared to be greater intention to use in-hours
GP surgeries but more disagreement with the recommended
treatment pathway for expert triage patients. Expert triage GPs
perceived that there was improved triage quality, enhanced
capacity and fewer delays to assessment. Both patients’ and
expert triage GPs’ responses indicated awareness of the need
to improve patient knowledge and to enhance appropriate use
of the service.
Conclusions Triage outcomes and interview responses
provide a positive account of the ‘expert triage’ model, although
some limitations were apparent from patient responses. Further
improvements in this GP out-of-hours service may also be
possible from implementing suggestions from participants’
responses in light of their experiences.

Keywords

There has been emphasis on evaluating service models prior to implementation and training to provide skills and knowledge
necessary for telephone consultations. The organisation and delivery of out-of-hours services have received extensive attention,
however, the impact of using an expert triage system on service quality and user and provider experience has received little
attention.

What does this paper add?

Cardiff and Vale out-of-hours service (Wales, UK) adopted an ‘expert triage’ model of care, which implemented a number
of strategies, such as training workshops, revised prioritisation algorithms, and triage targets. Improved outcome targets, and
positive user and provider experience were found from evaluating this service model. Implementation by other out-of-hours
services may improve service quality and patient and clinician experience further afield.

Background

There is increasing pressure on all unscheduled care services and
provider interest in how such services can be improved. In GP out-of-hours
services there is particular interest in whether experienced triage staff can
achieve greater quality of care, whilst also managing demand.

Ensuring that new service models are evaluated before they are
introduced is fundamental. This is particularly so for out-of-hours services as
they are associated with greater risk due to
clinicians and patients not knowing each other and the condition often being
urgent.[1] Cross-cultural analysis of out-of-hours care has revealed that several
different models exist alongside each other in most Western countries, with the
Accident and Emergency department being the most frequently used model, and
countries differing in the provision of Primary care centres and telephone
triage services.[2] Importantly, a significant
proportion of the countries who took part in the survey had plans to alter the provision of
out-of-hours care to large
scale organizations, reflecting
a prevalent measure for
managing demand for out-of-hours primary
care.[2] A previous survey regarded telephone triage favourably for accessibility
and patient satisfaction but negatively for satisfaction of out-of-hours
physicians. ² Emphasis has been placed on training courses to enhance
appropriate attitudes, skills and knowledge necessary for telephone triage to
aid patient and physician satisfaction. Improving awareness of when telephone
consultations are inappropriate, training in verbal sensitivity and guidance on
managing patient expectations were found to be important content of training. [3]
In addition to service provider and user satisfaction, higher quality of
telephone triage has been shown to be positively related to appropriateness of
decisions and accuracy in estimation of urgency.[4]Such findings illustrate the importance of targeting consultation
quality in training and supporting triage providers.

Triage models adopted in other
primary care services have provided mixed results. The out-of-hours provider
NHS 111 adopted a telephone triage intervention for non-emergency health
problems operating 24 hours 7 days a week.[5] The intervention was
operated by non-clinical call handlers using decision algorithms. Emergency
service use remained constant immediately after the intervention but there was
an increase in emergency care use with each month following implementation. [5] However, Kelly et al. conducted a survey of out-of-hours primary care models in
Wales and found telephone advice to be associated with increased patient
satisfaction and enablement compared to consultations in a treatment centre.[6] An expert triage model has been adopted by some out-of-hours services in the
Netherlands, although this triage system received mixed opinions as to whether
the quality of triage would be
sufficiently enhanced.[6] The service using the expert triage system had significantly longer mean call duration but call decisions resulted in less contact
with a GP either through telephone or face-to-face consultation.[7] The authors recognised that the differences may arise from comparing different
services rather than different triage systems; therefore, it cannot be proven
that these differences were a result of the expert system.[7] The present study rectified this problem; analysing
patient and GP experiences and
triage outcomes before and after implementation within the same service.

We aimed to examine the effects of the ‘expert triage’ service model
introduced by Cardiff and Vale Health Board’s out-of-hours service (Wales, UK)
on 1st April 2013. The service typically receives about 8500 calls per month.
Under the previous service model, non-clinical call handlers would obtain
symptoms from patients or their representatives and by protocols for
appropriate assessment, would offer the most appropriate treatment pathway. In
response to service pressures resulting from high proportions of patients being
classed as urgent and being offered face-to-face appointments, the ‘expert
triage’ model was adopted. Under this new model, all callers to the
out-of-hours service were triaged by a clinician, usually a GP, who would
recommend the most appropriate treatment pathway. Call handlers remain the first point of
contact; gathering case
information and prioritising cases according to prioritisation guidelines. The
triage clinician then calls back patients according to the prioritisation list.
A number of strategies were adopted in its implementation. Triage providers
attended training workshops which aimed to improve triage productivity,
communication skills and appropriate use of triage outcomes of appointments and
telephone consultations. The prioritisation
support systems were revised to reflect in-hours practice, triage targets were implemented, and
scheduled face-to-face appointments were lengthened from 10 to 12.5 minutes.
Pay rates also improved under the model, which was thought to facilitate
recruitment of GPs to the service. The aim of this study was to analyse patient
and GP experiences of the ‘expert triage’ service model and effects on triage
outcomes, particularly whether the changes were effective in overcoming the
outcome challenges present under the previous model.

Method

Overview

The ‘expert triage’ model was implemented on the 1st April
2013, aiming to improve triage quality and outcomes, and to improve training of
experienced triage GPs. The proportion of calls concluded by telephone advice,
face-to-face consultation or home visit, before and after the service change
was the principal outcome. This was complemented by interviews with patients
who had used the service before or after the changes, and with GPs involved in
expert triage.

Design

Telephone interviews were conducted with patients and face-to-face
interviews were conducted with GPs. Responses were analysed for themes and
subthemes. Triage outcome data was extracted from a statistics database held
within the out-of-hours service.

Participants

The patients under the ‘previous’ service model were recruited from the
Adastra patient database, a clinical patient of case details
from 1st January 2013 to 1st April 2013. This search
excluded teenage children (where follow-up may raise confidentiality issues) or dental calls. After two
rounds of invitations, 16 ‘previous’
service users had been recruited and provided responses, all of whom had used
the service in either February or March 2013. Twenty ‘expert triage’ patients
were also randomly selected from Adastra from lists of recent users during
June-July 2013.

The triage GP sample consisted of 19 triage practitioners who were
recruited from a list of 40 Cardiff & Vale triage providers based on their
willingness to participate. They included one GP who had left the service since
the adopted change, three who had left but re-joined the service under ‘expert
triage’, two medical advisors, and thirteen triage practitioners who had worked
for the service under both the ‘previous’ and ‘expert triage’ models.

Data
collection

Triage outcome statistics were
extracted before and after the service model change from a statistics database
updated monthly and maintained within the out-of-hours service. Triage GP and
patient experiences were explored through interviews, conducted with a question schedule, with both fixed
response and open-ended questions, and with field notes recorded during each interview. The interview schedules
were developed and revised with support from the head of unscheduled care;
telephone interviews were voice recorded and played back during data analysis
and face-to-face interviews were recorded in writing. Data were managed through
recording the case details and interview time for telephone interviews and GP
identity as ‘left’, ‘advisor’, ‘new’, or ‘both’ for face-to-face interviews.
Both patient samples were interviewed by telephone in July 2013 lasting an
average of 5 minutes, with those receiving triage under the ‘previous’ model
using the service in February or March 2013 and those under the ‘expert triage’
model using the service a few days prior to interview. Of the triage GP sample,
fifteen were interviewed
face-to-face in their in-hours surgeries and the remaining four took part in telephone
interviews, all lasting 30 to 45 minutes and taking place during July-August
2013. All telephone interviews were conducted from the triage centres.

Patients were asked questions
about their understanding and use of the triage information, and their
experience of the service. The GP sample were asked about the strategies and
targets implemented by the model and about their suggestions to improve the
service.

Data
analysis

The triage outcome data are
presented from before to after the service change in the form of a ‘run chart’
to depict change in treatment pathway outcomes across time and sustainability
of such change (see Figure 1).[8]

Figure 1: The proportions of cases who received appointments (PCC), telephone advice (TA), a home visit (HV) or a referral to an
Accident & Emergency (A&E) from October 2011 to June 2014. The arrows indicate the point of the service change.

The interview responses were
summarised descriptively, content analysis was undertaken, and themes
and subthemes were identified.

Results

Triage
outcomes

Changes in the proportion of
service users receiving telephone advice, face-to-face consultation or home
visits, before and after the service change are shown in Figure 1. The
proportion of service users receiving primary care centre appointments decreased
by approximately 11% following the service change and was maintained in the first fifteen months of the service. There was also a decrease
in recommended attendances to Accident and Emergency centres.

Patient
experiences

Although many patients using the ‘expert triage’ service reported
satisfactory outcomes in terms of their ability to understand (8/20) and cope
with their illness (7/20) (“I did not need an appointment in the end because I
understood the information over the phone”; “The information put me on the
right path of care, (I have) better understanding of the illness and
treatment”), there was some suggestion that ‘expert triage’ patients felt less
able to understand the telephone advice given or to cope with their illness in
some situations (fewer respondents reporting understanding the advice “very
well”, able to cope with illness; (Table 2). ‘Expert triage’ patients gave some
indication that it felt less easy to get a face-to-face appointment (“Very
easy” 2/7; “Easy” 5/7) (“I received out-of-hours care years ago.

It was better
before because they would definitely have given an appointment”), and that the assessment recommended
was not appropriate (almost half 9/20 indicating “not appropriate”) (“Advice
decision was not appropriate. I would have preferred an appointment”; “(I)
would have preferred an appointment, especially as I raised concern about
getting an appointment at my own GP”; “I am more anxious now than before as no
one has seen the problem. I have not seen anyone to reassure me”). These
patients also reported that they had used another service more often during the
same episode (10/20; usually the patients’ own GP in-hours) (“I went to my GP
surgery after to receive further information”). Among the users of the ‘expert
triage service’ who also had experience of using the ‘previous’ model (12/20),
comparisons between prior and present use of the out-of-hours
services were variable – some perceiving better or poorer quality advice this
time, or that telephone advice was more or less favourably received. These
respondents perceived shorter waiting times to receive advice (“I received
out-of-hours advice before. It was better this time. The information was better
and I waited less time for the doctor to call back”; “I received advice before.
This experience was better, (the) response was much quicker”),
but no respondent reported perceiving longer appointments when seen
face-to-face. Themes and subthemes of patient responses are provided in Table 1 and Table 2.

GP
experiences

GPs now providing the service gave generally positive views about the
new model of out-of-hours care. The service change was felt to have
helped to address the challenges associated with the previous model, in
particular triage delays, capacity and quality (“Triage has got better since
the new system. More doctors triaging has made it easier”; “I’ve seen a change
in patient expectations since the new model, I was seeing a lot of patients
that did not need to be seen before”). The triage environment was perceived as
supportive; a result of effective training (though which could be improved
further) (“Having people in the
same place is more supportive, I can talk to other doctors”; “There are other
GPs around to talk to and ask their opinion. You gain tips from listening to
other GPs”). A theme of responses was that GPs felt pressurised to achieve
targets of telephone advice conclusions (9/19), and that they would value more
time to discuss matters with patients (“When patients have high expectations it is difficult to
ignore. More time is needed to
persuade and reassure”). However, a subtheme of responses outlined that
GPs were mainly content with the 60% telephone advice target, with a range from
40-60% in terms of what they felt was an appropriate target. Most GPs (16/19)
felt that patients had (too) high expectations of the service (“Patients need
to be educated of what the out-of-hours service is for; it is not an extension
of in-hours”), although a subtheme of responses reflected negotiation and reassurance being possible, and that patients were generally accepting
of the new model and advice
given. Overall they identified potential further improvements that could be achieved through patient
education, call handler and GP training, analysis and feedback on triage
performance, implementing Clinical Professional Development and increasing
consultation times for complex cases.

Discussion

Summary

Triage outcomes changed from before to after the introduction of the
‘expert triage’ model of out-of-hours service delivery, with greater
proportions of calls concluded with telephone advice and fewer patients being
seen at out-of-hours centres and A&E centres. These changes were sustained
for fifteen months. Patient
interview responses indicated that the proportion of patients who used the triage advice
given remained constant after introduction of ‘expert triage’ although there
was some indication of less understanding of telephone advice, more
disagreement with the triage recommendation, and greater intentions to use
another service under expert triage. Clinicians reported perceived improvements
in triage delays, capacity and quality, and that they did not feel overly
pressurised by the triage outcome targets. Improvement suggestions included
further public education about appropriate use of services, management of
patient expectations, and further recruitment and training for triage
practitioners and call handlers.

Strengths
and Weaknesses

This study complemented activity-based triage outcomes with interviews
to assess service user and provider experience of these service changes.
Participants elaborated on responses and made suggestions about how the service
could be improved based on their experiences. However, patient interviews
lasted an average of 5 minutes which also restricted the length of elaboration.
Although interviews with triage providers lasted for 30 to 45 minutes, it
enabled a large amount of data to be gathered from each provider. Subject to
recall bias possibilities, the responses from both triage users and providers
are likely applicable to other services whose aim is to overcome challenges associated
with pressures from patient expectations and demand for face-to-face
appointments.

An important caution is that influences on A&E usage are not available, only the recommendation
about whether to use A&E services. Furthermore, the safety of triage
outcome pathways was not followed up; the change in triage outcomes may not
have been optimal for patient safety. A weakness of the study is that patients
from the ‘previous’ service model took part in interviews, on average, four
months after they had used the service, making recall perhaps more variable in
this group. Context of other literature Triage outcomes changed following the
implementation of the ‘expert triage’ model with fewer patients being given primary care
centre appointments and referrals to A&E centres. Patients had similar use
of triage advice although greater disagreement with the triage outcome.
Furthermore, patients and GPs who experienced both service models perceived
improvements in triage delays and quality. Changes to out-of-hours services
have been shown elsewhere to
influence presentation rates in emergency centres.⁹ Perhaps in contrast to the
recommendations for A&E usage in this study, however, Thompson et al. found
that triage by appropriate clinicians increased the proportion of patients
attending emergency care departments for non-trauma conditions, especially
during overnight periods.[9] Elsewhere, evaluation of other
out-of-hours organisational models has found telephone triage to be favourable
for patient accessibility and satisfaction but less favourable from clinician
satisfaction perspectives².

The present study supports those patient
accounts identified, although
in contrast, triage GP satisfaction was also high with only a few suggestions
for improvement.

An issue identified with the
present study was that safety of triage
outcomes was not analysed. Although there have been a number of safety
evaluations of out-of-hours triage revealing that telephone triage is generally
a safe practice. Huibers et al. conducted a review of telephone triage and
found triage to be safe for 97% of patients who contacted services. [10]Of the
studies reporting adverse events just below half reported mortality, medical
errors and hospitalisations¹º. In an evaluation of the Manchester Triage System
which aimed to reduce the number of
patients classed as urgent, triage identified less urgent patients safely and resulted in low hospitalisation
following discharge for most patient groups. [11]

Among UK health service users,
understanding that health resources are limited and that others may perhaps
have greater needs is variable.[12] There was evidence of concern about
appropriate use of health services, and patients reporting that they had
consciously limited their own service use because they worried that they were
“wasting clinician time”.[12] Discrepancy between patients’ expectations and GP
recommendations is evident in previous literature. [12-14]

With mixed effects on patient
satisfaction and enablement, Brown et al. found that patients who received
advice other than that
expected were still satisfied with the telephone triage, whereas Egbunike et al.
found that patient expectations moderated the relationship between user concern
and satisfaction with a greater intention to re-consult with the same service
for the same illness episode. [13,14] In this study both patients and
triage GPs were concerned about the expectations or perspective of the other,
but patient agreement with the assessment recommendation was suboptimal. In line with this, Brown
identified the importance of patient trust, finding effective communication of
warmth, openness and
understanding of the patient’s interests were the most effective strategies in
upholding trust. [15] Findings from the present study, that patients
were not fully accepting of the recommended treatment pathway under the ‘expert
triage’ model, may suggest
that patient trust and confidence in the triage process need to be further improved.

Implications
for practice and research

The before and after
comparisons in this study show that the ‘expert
triage’ model has had an appreciable impact on this service, with fewer
face-to-face consultations and more telephone advice concluding calls, less
perceived delay in triage call back and in providing appointments, and encouragement
of patients to use their in-hours practice. A concern from service providers
that there would be a rise in complaints from patients, or GP in-hours and
A&E providers about diverted demand, was not borne out. It also encouraged
the return of nine doctors to the out-of-hours service (among a total of 40).
Continued and wider adoption of the ‘expert triage’ model in out -of-hours
services may lead to a decline in service pressures for the out-of-hours
services, although impact on in-hours primary care and A&E services require
evaluation. Findings from both service users and service providers were that
patients have high, and sometimes inappropriate, expectations of the nature of
the service and use of assessment pathways. This may provide a possible
explanation as to why slightly fewer patients indicated understanding telephone
advice under the new model; they did not agree with this treatment pathway and
were therefore reluctant to utilize the information. Greater patient education
about appropriate service use, for quality and safety purposes, is necessary, and findings in
this study indicate that there
would be patient and public support for such initiatives. In addition, this
study evaluated the Cardiff & Vale out-of-hours service for a short time
after the ‘expert triage’ model
was implemented. Further research would benefit from longer term assessment of the impact of the service
model on quality, safety, and patient and clinician experiences both in this location and if adopted further
afield. Further evaluation should
also use more detailed methods to assess patient experiences, including mixed
methods approaches and with larger samples, to understand both the experiences
in more depth and also the
influences on help-seeking behaviour across the whole system of unscheduled care. Further research
should also focus specifically
on the quality and safety of telephone triage.

Conclusions

Adoption of the ‘expert triage’
model for this out-of-hours service has led to an increase in proportion of calls
concluded by telephone advice instead of face-to-face consultations. As such
the perceived associated improvements in triage and consultation delays,
service quality, and positive experiences for participating clinicians,
alongside largely maintained service user experiences, warrant continued
implementation of this model of out-of-hours care. Caution and further
evaluation of the effects on other primary care services is required, as are
further improvements to address service users’ suggestions and to enhance
public understanding and expectations.

Acknowledgement

We thank the staff at Cardiff
& Vale Primary Care Division for assistance with patient and GP
recruitment, and provision and interpretation of statistical data. We also
thank the patients and triage GPs who provided responses.